Prevalence of personal, work-related and patient-related burnout during the COVID-19 pandemic and its associated factors among healthcare workers in health clinics in the district of Manjung, Perak: A cross-sectional study

Abstract Introduction: Burnout is a syndrome characterised by physical, emotional and mental exhaustion that results from a long period of involvement in an overwhelming work condition. It is prevalent among frontline workers. This study aimed to identify the prevalence of burnout among primary healthcare workers in the district of Manjung, Perak and determine the factors associated with burnout. Methods: This cross-sectional study was conducted among healthcare workers in seven health clinics located in the district from August to September 2022. The self-administered validated Malay version of the Copenhagen Burnout Inventory and the Malay version of the Multidimensional Scale of Perceived Social Support were used. These instruments consisted of 31 questions rated on a 5-point Likert scale. The scores were then summed up to determine the burnout level. Data were analysed using SPSS version 20. Simple logistic regression analysis was performed. Thereafter, multiple logistic regression analysis was conducted to determine the factors associated with burnout. Results: A total of 224 participants were included. Among them, 61.6% were nurses; 21.4%, doctors; and 17.0%, assistant medical officers. The prevalence of personal burnout was 31.3%; work-related burnout, 16.5%; and patient-related burnout, 5.4%. The factors associated with burnout were the highest educational level, financial difficulties and low perceived social support from friends and significant others. Conclusion: Healthcare workers in Manjung health clinics have a higher prevalence of personal burnout than work- and patient-related burnout. The findings of this study provide early insights and guidance for possible interventions.


Introduction
Burnout is a syndrome due to stress from chronic workplace conditions that has not been managed successfully, characterised by physical and emotional exhaustion, increased mental distance from one's job and decreased professional e cacy according to the 11th Revision of the International Classi cation of Diseases. 1,2It can result in negativity in relation to one's job, especially when dealing with patients, thus resulting in decreased professionalism and work e cacy. 3 Burnout is prevalent among healthcare workers, especially frontliners. 3In the National Health and Morbidity Survey conducted in 2015 in Malaysia using the 12-item General Health Questionnaire, the prevalence of mental health problems among the general adult population was reported to be 29.2%. 4Burnout is found to be a risk factor for suicide and low quality of life, as a ected individuals are prone to experiencing depression, anxiety and sleep di culties. 5It is associated with sleep deprivation, family issues and feelings of being overwhelmed by assigned tasks. 5erefore, measures aimed at reducing the stress levels of healthcare workers are needed to improve their general well-being and quality of life, consequently enhancing their e ciency at work. 5 COVID-19 has emerged as a global health issue, which has resulted in an unprecedented demand for healthcare workers worldwide.It has caused a signi cant burden on the healthcare system. 6disease has been associated with a remarkable rise in reported feelings of burnout.During the pandemic, healthcare workers faced issues such as insu cient personal protective equipment, risk of exposure to the disease, shortage of manpower, a lack of childcare, limited resources and lengthy working hours.[6][7][8] Long working hours might cause physical exhaustion and increase the susceptibility to psychological distress.Consequently, these factors could worsen the quality of life and reduce the con dence and e cacy to perform well under extended working hours.6,7 Healthcare workers perceived that the quality of care and patient safety might be a ected when their workload is increased and working hours are extended.8 A systematic review of studies conducted among healthcare workers in India demonstrated a prevalence of burnout ranging from 23% to 27%. 9 In another study, the prevalence of burnout among healthcare providers in hospitals in Taiwan was reported to be 40.3%.10 A study in Indonesia reported a prevalence of burnout ranging from 70% to 88.3%.11 Some studies conducted on burnout among healthcare workers in Singapore showed burnout rates ranging from 40% to 60%, with most studies using the Maslach Burnout Inventory.[12][13][14] In a study conducted in Malaysia, the prevalence of burnout was 51.3% among emergency healthcare workers.15 Another study performed in Sabah showed that the prevalence of personal, workrelated and client-related burnout was 61.2%, 48.8% and 39.8%, respectively.16 ere are many inventories used to assess burnout.In this study, the Copenhagen Burnout Inventory (CBI) was used to assess burnout among healthcare workers, as it is a valid and reliable instrument that can be easily applied among medical professionals compared to other inventories.17 e factors associated with burnout are job overload, frequent involvement with angry or di cult clients, stereotyped notion of underpaid work and lack of clear guidelines.18 Other factors signi cantly associated with burnout include younger age, underlying medical conditions, long working durations, direct dealing with patients with COVID-19, a lack of self-perceived social support at the workplace and inadequate childcare support.19 Working experience and working in di erent medical departments are also associated with burnout.17 is information is important to facilitate the planning of interventions to reduce the prevalence of burnout and further prevent progression to multiple implications related to personal and patient care, such as decreased professionalism, lack of empathy, increased medical errors, compromised patient safety and lack of teamwork. To ate, there is a paucity of research on burnout among sta in health clinics during the pandemic, especially in Malaysia.Awareness, preventative strategies and early diagnoses can improve burnout among healthcare workers and thus improve their quality of life.

Methods
is cross-sectional study was conducted from August to September 2022 among healthcare workers in seven health clinics in Manjung District.Manjung District is located in the south-western part of Perak State.It covers an area of 1113 km 2 with a population of nearly 250,000 people and a population density of 200/km 2 .
e district has few hundreds of primary care frontliners.Due to this large number, Manjung District was deemed an appropriate location for this study.Healthcare workers such as doctors, assistant medical o cers and nurses were included as the study population because they were the frontliners who dealt with patients most of the time during the pandemic.In particular, doctors, assistant medical o cers and nurses who were aged 18-60 years and were practising in health clinics in Manjung District were included.Conversely, healthcare workers who had pre-existing psychotic disorders, had a bipolar mood disorder, used illicit drugs, had alcohol dependence, were from other agencies doing attachment in the health clinics temporarily and were doing further studies (e.g.degree or post-basic studies) were excluded.e response rate was 100% among all categories of healthcare workers including doctors, assistant medical o cers and nurses.e formula for sample size calculation for prevalence studies, 15 with a nite population size of 234 and precision of 0.025, was used.e sample size of 204 was calculated using the simple proportion formula for nite populations based on a prevalence of burnout among healthcare workers of 51.3%.Considering a 10% drop out rate, 224 participants were recruited.A total of 234 healthcare workers ful lled the inclusion criteria.Among them, 224 were chosen using the simple random sampling function in the EpiCalc 2000 software (Brixton Health, www.brixtonhealth.com).
A data collection form that was used has 3 parts.It was pretested among ve healthcare workers to assess its feasibility in the local setting.
e results of the pretesting were not included in the nal analysis.e questionnaire used had three parts, and permission was sought to use them.e rst part of the questionnaire collected basic sociodemographic and clinical data including age, race, sex, religion, marital status, highest educational level, occupation, monthly household income, number of dependants, duration of service, distance between the house and workplace, medical conditions, working shift, working hours in a week, nancial problems, problems with colleagues and family issues.e second part consisted of the self-administered validated Malay version of the CBI.e CBI is used to measure occupational burnout, with excellent psychometric properties, and is available in the public domain. 19It has three dimensions including personal (six items), work-related (seven items) and patientrelated burnout (six items) (Cronbach's alpha coe cient=0.83-0.87 for the three dimensions). 19Each question is scored on a 5-point Likert scale (never, seldom, sometimes, often and always).Each item is rated as follows: always/to a very high degree (score=100), often/to a high degree (score=75), sometimes/somewhat (score=50), seldom/to a low degree (score=25) and never/to a very low degree (score=0).e score for the set of questions for each of the three burnout dimensions was added, and the average of the scores was calculated.An average score of ≥50% is considered to indicate burnout.
e CBI was also validated in the pandemic context, with a Cronbach's alpha coe cient of 0.94. 20e third part comprised the selfadministered validated Malay version of the Multidimensional Scale of Perceived Social Support (MSPSS-M).e MSPSS-M is used to assess social support from three sources: family, friends and signi cant others.It has 12 items, with four items for each source of support.Each item is scored on a 7-point Likert scale ranging from very strongly disagree (score=1) to very strongly agree (score=7).
e total social support score is the sum of the scores for all 12 items.e greater the score, the higher the level of social support.Items 1, 2, 5 and 10 relate to support from signi cant others; items 3, 4, 8 and 11, from family; and items 6, 7, 9 and 12, from friends.e item scores are summed and then divided by 4 to calculate the subscale scores.e total scale score is calculated by adding all 12 item scores and then dividing the sum by 12.A total score of 1-2.9 indicates low support; 3-5, moderate support; and 5.1-7, high support.e instrument showed good internal consistency (Cronbach's alpha coe cient=0.89),parallel-form reliability (0.94) and test-retest reliability (0.77) (Spearman's rho, P<0.01). 21All participations were voluntary, and written consent was obtained before questionnaire completion.
Permission to conduct this study was acquired from the NMRR [approval number: NMRR 22-01231-B0J (IIR)].Data were analysed using SPSS version 20.Descriptive analysis was performed using frequencies and percentages.Age, monthly household income, duration of service, number of dependants, distance of the workplace from the house and total working hours per week were presented as medians, as these data were not normally distributed.Simple logistic regression was used to select variables for further analysis.All variables with P-values of <0.25 and clinically signi cant variables were included in multiple logistic regression. is P-value was set higher than the level of signi cance to allow for more important variables to be included in the model.
e independent factors associated with burnout were identi ed via multiple logistic regression.P-values less than 0.05 were considered statistically signi cant. 16

Results
e median age of the participants was 37 years (IQR=10.0).Majority of the participants were Malays (87.5%), followed by Indians (6.7%) and Chinese (4.0%).ere were more female participants (80.8%) than male participants (19.2%).Most participants held a diploma (47.8%).Approximately 61.6% of the participants were nurses.e sociodemographic and clinical characteristics of the participants are detailed in Table 1.e prevalence of personal burnout among the participants was 31.3%;work-related burnout, 16.5%; and patient-related burnout, 5.4%.e assistant medical o cers and sta nurses had 3.93 times higher odds of developing personal burnout than the community nurses [95% con dence interval (CI)=1.55,10.01; P=0.004].e doctors had 8.36 times higher odds of experiencing personal burnout than the community nurses (95% CI=3.05, 22.95; P=0.000).
e participants with nancial problems had 5.93 times and 4.96 times higher odds of developing personal burnout (95% CI=2.13, 16.52; P=0.001) and work-related burnout (95% CI=1.98, 12.42; P=0.001) than those without, respectively.e participants with low perceived social support from signi cant others had 14.91 times higher odds of experiencing personal burnout than those with high perceived social support from signi cant others (95% CI=1.42, 157.03;P=0.024).e participants with low perceived social support from friends had 49.50 times higher odds of developing patient-related burnout than those with high perceived social support from friends (95% CI=4.45, 550.32;P=0.010) (Table 2).

Discussion
e overall prevalence of personal burnout among the healthcare workers in health clinics in Manjung District was 31.3%;work-related burnout, 16.5%; and patientrelated burnout, 5.4%.
is nding is consistent with that of a study conducted in Japan, wherein the overall prevalence of burnout was 31.4%. 22However, the study was performed in a tertiary hospital.Conversely, the prevalence noted in the present study is much lower than that reported in a study on Malaysian healthcare workers: 53.8%, 39.1% and 17.4% for personal, work-related and patient-related burnout, respectively. 18s could be because this study was conducted when Malaysia was in its third month under a movement control order during the initial phase of the COVID-19 pandemic; in comparison, our study was performed among doctors, assistant medical o cers and nurses in health clinics in a district during the end of the pandemic, when the number of cases had signi cantly dropped and movement control measures were eased.Even before the pandemic, high levels of personal, workrelated and patient-related burnout were also found in a study conducted among doctors in Sabah, with rates of 57.1%, 48.8% and 30.4%, respectively.23 e current study showed that the healthcare workers who held a diploma had higher odds of experiencing personal burnout than those who completed secondary school only.e healthcare workers who held a diploma were the assistant medical o cers and sta nurses.
e participants who held a degree and above had 8.4 times higher odds of developing personal burnout than those who completed secondary school only.Similarly, Font et al. showed that doctors faced higher levels of burnout than nurses in Spanish oncology units. 24Another study found that workers employed in government service had relatively lesser job exibility and autonomy than those employed in the private sector. 25 Healthcare workers who held a diploma encountered higher job demands surpassing resources. 25ncreased workload among healthcare workers including multitasking during the pandemic has resulted in higher risks of burnout by depleting the capacity of workers to meet their job demands. 26Further, negative emotions of patients and colleagues have triggered similar emotions in healthcare workers with a diploma, making them more susceptible to burnout. 27 also found that personal and workrelated burnout were associated with nancial di culties. is is consistent with the ndings of a study among radiology trainees, wherein nancial constraint was a risk factor for burnout. 26Similarly, nancial di culties were found to be associated with high burnout levels among a female general population in another study. 25se ndings indicate that further attention is needed to assess and help healthcare workers with nancial constraints through, for example, training in nancial planning via courses. 28If nancial problems are solved, the risk of personal and work-related burnout can be reduced.
Social support from friends and signi cant others plays an important role in reducing the risk of burnout by acting as a bu er.Providing support can be an essential psychological approach with better e cacy than pharmacological therapy.A lack of social support is related to increased burnout levels.Social support from friends is associated with lower work-related burnout levels. 28s suggests the importance of creating policies that do not mandate separating frontline healthcare workers from their friends or signi cant others.Healthcare workers can easily seek psychological support from their family members to relieve stress from work instead of feeling isolated or helpless. 26cording to a systematic review, decreased social support is a vital risk factor for the development of psychological issues among healthcare workers, especially during disasters. 29upport from families, friends, colleagues and healthcare organisations can provide healthcare workers the opportunity to alleviate negative feelings and emotions, which can then reduce the risk of burnout syndrome. 29,30Individuals can cope with di culties by receiving support from their signi cant others. 28Several studies have shown that strong social support during the COVID-19 pandemic can reduce feelings of isolation and, consequently, the risk of burnout among healthcare workers. 28,30limitation of this study is that the ndings might not be generalised to other healthcare workers, as their job scopes di er.Nonetheless, the study provides an estimation of the prevalence of burnout among healthcare workers in a similar workplace setting in Malaysia.Another limitation is the possibility of reporting bias, as the burnout data were obtained using a self-administered instrument.Despite the limitations, the ndings provide insights into burnout among healthcare workers in the country.

Conclusion
Burnout is prevalent among healthcare workers in Manjung District.Several measures could be implemented to reduce the mental health impact of burnout on healthcare workers, including mental health screening, immediate access to mental healthcare services, early intervention and establishment of support groups.Further studies can be conducted in the country to better identify the issues and contributing factors of burnout.

How does this paper make a di erence in general practice?
• is study examined the determinants of burnout among healthcare workers in primary care in Manjung District.• e ndings could assist public healthcare authorities in designing a targeted promotional and intervention programme to reduce the risk of burnout among healthcare workers in primary care.

Table 1 .
Sociodemographic and clinical characteristics of the participants.

Table 2 .
Multiple logistic regression analysis of the factors associated with burnout among the participants.